Implementation of aspirin use during pregnancy in community midwifery-led care in the Netherlands: A pilot survey

INTRODUCTION Aspirin nowadays is widely used in pregnancy, but implementation among gynecologists took nearly four decades. For a complete insight in the implementation of aspirin, community midwives are to be involved. Community midwives do not have authority to prescribe aspirin and have to refer to a general practitioner or consultant obstetrician for a prescription. METHODS The study was an online, national pilot survey about the implementation of aspirin use during pregnancy among independently practicing community midwives consisting of 29 items with five categories: background, advising, prescribing, possible indications, and clinical practice. RESULTS Forty-seven community midwives completed the survey between April and May 2021. All respondents had experience on advising aspirin use in pregnancy. History of preterm pre-eclampsia or HELLP syndrome was identified as a risk factor for developing utero-placental complications by 97.9% of the community midwives. Moderate risk factors in women with otherwise low-risk pregnancy were identified by >75% of the participants. Practical issues in prescribing aspirin were experienced by one-third of the respondents. Suggestions were made to obtain authority for community midwives to prescribe aspirin and improve collaboration with consultant obstetricians and general practitioners. CONCLUSIONS Community midwives seem to be adequate in identifying risk factors for developing utero-placental complications in women with otherwise low-risk pregnancy. Practical issues for prescribing aspirin occur often. Obtaining authority for community midwives to prescribe aspirin after education should be considered and consulting a consultant obstetrician should become more accessible to overcome the practical issues. Further educating community midwives and general practitioners might improve implementation rates and perinatal outcomes.


Introduction
We would like to invite you to respond to our survey.First of all the purpose of the questionnaire is explained followed by what we hope to learn more about the implementation of aspirin in pregnancy among community midwives by means of your input.
The drug aspirin can be obtained through drugstores or pharmacies and has the brand name aspirin (generic name acetylsalicylic acid) or ascal (generic name carbasalate calcium) and is given during pregnancy to reduce the risk of uteroplacental complications such as hypertensive disorders in pregnancy and fetal growth restriction in women at increased risk.
An increasing number of pregnant women have an indication for aspirin use in pregnancy according to current guidelines.Up-to-date knowledge about placental complications in pregnancy and the riskreducing effect of aspirin is established in the guideline 'Hypertensive disorders' of the Dutch Society of Obstetrics and Gynaecology (NVOG) since December 2018 and in the module 'Acetylsalicylic acid' which was published in October 2019.The Royal DutchAssociation of Midwives (KNOV) published a module 'Ascal in case of elevated risk of hypertension' in January 2019 and a scientific response 'Ascal in women with a history of a dysmature newborn' in August 2020.These documents are supported by a KNOV leaflet for pregnant women on 'Aspirin'.This leaflet contains information for pregnant women with an indication for aspirin use in pregnancy.The information includes the reason for aspirin use during pregnancy and risk reduction, as well as practical information including timing of the gestational age to start aspirin use .
The purpose of this study is to gain a better understanding of: -Different aspects around counselling aspirin use in pregnancy.
-Suggestions for further implementation of aspirin use in pregnant women with an indication.
We have calculated how many people need to complete the questionnaire to be able to give a reliable statement.This is approximately 330, based on approximately 2.500 practicing community midwives.
With this, we reach the desired 95% confidence level and 5% has been taken into account as an acceptable margin of error.You understand that we need your input.
Since the majority of pregnant women in the Netherlands have their (early) pregnancy check-ups with a community midwife, it is important to know whether women with an indication for aspirin are reached and if reached, if this is in time.By answering this questionnaire, you will help us gain more insight into this subject.You cannot give right or wrong answers.The questionnaire is not a test of knowledge about aspirin in pregnancy.The questionnaire was prepared by the physician-researcher, clinical midwife and gynecologists from the Amsterdam UMC location VUmc in close cooperation with the Hellp Foundation.We ask you to fill out the questionnaire honestly to get a true picture of current practice.To give you the freedom to complete the questionnaire honestly, the digital questionnaire has been anonymized.Thus, we cannot find out who completed the questionnaire.
The questionnaire will take about 20 minutes to complete.If you wish to participate, please check below.Your consent will be recorded and the questionnaire will become accessible to you.
Checkbox I hereby confirm that I am working as a community midwife.
Checkbox I hereby give my consent to participate.
➔ If both checkbox were checked, the questionnaire became available.
Once again, we would like to thank you very much for your time and participation.

indications for aspirin in pregnancy 21
. Below is a list of clinical situations with possible indication for aspirin in pregnancy.Please answer if you would set an indication for aspirin in pregnancy or not.In case at least one of the above clinical situations was answered with 'No, not well informed', go to question 22.If not, go to question 23.HELLP, haemolysis elevated liver enzymes low platelets syndrome; FGR, fetal growth restriction; SLE, systemic lupus erythematosus; APS, antiphospholipid syndrome; BMI, body mass index. *